RESEARCH AND PRACTICE

Asian American Women in California: A Pooled Analysis of Predictors for Breast and Cervical Cancer Screening Neetu Chawla, PhD, MPH, Nancy Breen, PhD, Benmei Liu, PhD, Richard Lee, BS, and Marjorie Kagawa-Singer, RN, PhD, MA, MN

Cancer is the leading cause of death among Asian American women, with breast cancer and cervical cancer being 2 of the most commonly diagnosed types of cancer among this population.1---6 Although Asian American women have lower mortality rates for breast cancer compared with women from other racial/ethnic groups, existing research suggests that they have later cancer stage at diagnosis,3 younger age at diagnosis,7 and poorer survival among certain subgroups.8,9 Notably, studies have highlighted significant variation in cancer risk factors and differential cancer burden among Asian nationalities.4---6 Therefore, researchers have increasingly made efforts to disaggregate data on Asian Americans for analyses to identify subgroup differences. In one study conducted in California, McCracken et al.10 found that Vietnamese women had the highest mortality rates for cervical cancer, whereas Filipino women had the highest mortality rates for breast cancer. Another study conducted by Bates et al.11 found that Vietnamese and Korean women had the highest rates of cervical cancer mortality compared with other Asian women and White women. Despite a clear need for cancer screening among all Asian American women, their screening rates for breast and cervical cancers remain well below national objectives promoted by Healthy People 2020.12,13 Miller et al.2 found that 73.7% of all Asian women reported a mammogram in the past 2 years— nearly 10% lower than the Healthy People 2020 objectives of 81.1%, and lower than all other racial/ethnic groups except for American Indians or Alaska natives.12 In addition, Asian American women consistently have the lowest rates of cervical cancer screening, with 65.6% reporting a Papanicolaou (Pap) test in 2008.2 This rate was almost 10% lower than screening rates for White women and nearly 30% lower than the national recommendation of 93.0%.12 Additional research has noted that these disparities in breast and cervical cancer

Objectives. We examined patterns of cervical and breast cancer screening among Asian American women in California and assessed their screening trends over time. Methods. We pooled weighted data from 5 cycles of the California Health Interview Survey (2001, 2003, 2005, 2007, 2009) to examine breast and cervical cancer screening trends and predictors among 6 Asian nationalities. We calculated descriptive statistics, bivariate associations, multivariate logistic regressions, predictive margins, and 95% confidence intervals. Results. Multivariate analyses indicated that Papanicolaou test rates did not significantly change over time (77.9% in 2001 vs 81.2% in 2007), but mammography receipt increased among Asian American women overall (75.6% in 2001 vs 81.8% in 2009). Length of time in the United States was associated with increased breast and cervical cancer screening among all nationalities. Sociodemographic and health care access factors had varied effects, with education and insurance coverage significantly predicting screening for certain groups. Overall, we observed striking variation by nationality. Conclusions. Our results underscore the need for intervention and policy efforts that are targeted to specific Asian nationalities, recent immigrants, and individuals without health care access to increase screening rates among Asian women in California. (Am J Public Health. 2015;105:e98–e109. doi:10.2105/AJPH. 2014.302250)

screening among Asian women have persisted over time for many groups.14---19 Asian American women experience significant challenges and barriers to cancer screening, with notable differences by Asian nationality. Some factors associated with this heterogeneity include disparate levels of access to care,20---27 socioeconomic status,26---28 English proficiency,29,30 immigration status and length of US residency,23---25,27,31---33 screening-related knowledge,24,34,35 and health beliefs among Asian women.22,26,35,36 Studies have also documented that several Asian communities tend to use health care services for treatment rather than for prevention.37---39 Available research suggests that Asian American orientation toward preventive behaviors includes using complementary and alternative medicine rather than health care services for prevention of disease and may be influenced by low knowledge levels about the technology of Pap tests and mammograms.40---42 Additionally, studies have found that some Asian American

e98 | Research and Practice | Peer Reviewed | Chawla et al.

communities associate cancer with “a death sentence” and describe fatalism as a barrier to cancer screening.43---45 Until release of the California Health Interview Survey (CHIS), population-based data on Asian Americans were limited by small sample sizes that prevented the ability to disaggregate data on Asian American subgroups. One study that used CHIS data found a wide range of screening rates among Asian American women, with certain groups facing greater disadvantage, such as Vietnamese and Southeast Asian women.46 However, this study did not examine changes in cancer screening trends over time. In our study, we pooled data from the 2001 to 2009 CHIS to assess breast and cervical cancer screening rates for 6 different Asian American subgroups and examined the following research questions: 1. What are the patterns of breast and cervical cancer screening among Asian American

American Journal of Public Health | February 2015, Vol 105, No. 2

RESEARCH AND PRACTICE

women in California, and how have they changed over time? 2. Which subgroups of Asian American women have lower screening rates? 3. What differences and similarities exist in factors associated with screening use among Asian Americans? Findings from this research may provide helpful insights for interventions targeting Asian American women and for future research in this diverse population.

METHODS Our study sample was derived from the CHIS, a random-digit-dialed health survey conducted in English, Spanish, and 4 Asian languages (Cantonese, Mandarin, Korean, and Vietnamese).47,48 The 2001 survey was also conducted in Khmer. We pooled data from 5 cycles of CHIS from 2001, 2003, 2005, 2007, and 2009 surveys to help increase the stability of estimates for Asian American nationalities. The weighting factor used for each CHIS cycle was 0.2. We examined Pap test and mammography use among Asian American women overall and among Chinese, Filipino, Japanese, Korean, South Asian, and Vietnamese nationalities to explore predictors of cancer screening, detect differences between Asian American ethnic groups, and examine screening trends over time. Pap test receipt was not included in the 2009 CHIS; therefore, results for cervical cancer screening include pooled data from 2001, 2003, 2005, and 2007 only. The overall response rates for the landline and list-assisted adult samples ranged from 37.7% in 2001 to 17.7% in 2009, which are comparable to the Behavioral Risk Factor Surveillance System rates for equivalent years.49,50 We conducted analyses on 7865 Asian American women aged 21 to 64 to assess rates of Pap test receipt and on 4521 Asian American women aged 50 to 74 to assess mammography rates.

Measures Dependent variables. Dependent variables were Pap test receipt in the past 3 years and mammography receipt in the past 2 years. The question used to create the variable for Pap tests was “How long ago did you have your most recent Pap smear test?” Similarly, the item used to create the screening variable for mammography was “How long ago did you

have your most recent mammogram?” Individuals were categorized as “yes” if they received screening tests within the defined time frame and “no” if not. Missing and nonresponse data for these variables were dropped from final analyses. Women who reported a hysterectomy were not included in analyses of Pap test use. Independent variables. Independent variables were survey year, Asian nationality, and sociodemographic, acculturation, and health care access measures. Survey year accounted for changes in screening use over time. Asian nationality was defined by the “Asian9” variable in the CHIS data set, which included Chinese, Filipino, Japanese, Korean, South Asian, Vietnamese, Cambodian, other Southeast Asian, and other Asian/multiple race. We did not conduct nationality-specific analyses for Cambodians, other Southeast Asians, and other Asian/multiple race because of small sample sizes. We tried to combine Cambodians and Southeast Asians into a single group, but the sample size remained too small to produce reliable estimates. All tables present a total column for all Asian Americans; these data include Southeast Asians and other Asian/multiple race. Sociodemographic variables included age (21---29, 30---39, 40---49, 50---64 for Pap testing; and 50---64, 65---74 for mammography), marital status (married or living as married/ other), education (high school education or less, any college or technical school, college graduate or higher), and income (< 200% of federal poverty level; ‡ 200% of federal poverty level). Acculturation variables included percentage of life spent in the United States (0%---24.99%; 25%---49.99%; 50%---99.99%; 100%) and English proficiency (yes/no). Finally, health care access variables included health insurance (uninsured, public only, some private health maintenance organization [HMO], some private non-HMO), having a usual source of care (yes/no), and number of doctor visits in the past 12 months (0, 1---2, 3 or more). We based our variable selection on literature on cancer screening both in the general US population and in the Asian American population. Missing and nonresponse data for independent variables were eliminated from final analyses.

Data Analysis We calculated descriptive statistics for characteristics and screening rates among Asian

February 2015, Vol 105, No. 2 | American Journal of Public Health

American women in our study sample. We examined bivariate associations between screening and independent variables to select relevant predictors of cervical and breast cancer screening among Asian American women. General health status was included in bivariate analyses but subsequently removed from multivariate analyses because of lack of significance with screening. We conducted multiple logistic regressions on selected independent variables. Models stratified by Asian nationality included survey year, sociodemographics, acculturation, and health care access. Models conducted on the aggregate Asian sample included these variables as well as Asian nationality. We calculated predictive margins and 95% confidence intervals. The predictive margins are adjusted percentages directly standardized to the distribution of the covariates for the population that the sample represents.51 All analyses were weighted to address the complex CHIS design and to produce estimates that were representative of the California population. We used SAS 9.2 and SUDAAN 10.0.1 software to conduct all analyses.52,53

RESULTS Table 1 presents descriptive statistics for Asian American women aged 21 to 74 years in the pooled CHIS sample. In the total Asian American sample, most individuals were younger than 50 years (67.8%), were married (70.7%), had some college education or higher (73.4%), had incomes greater than 200% of the federal poverty level (71.6%), had some private HMO insurance (55.4%), had a usual source of care (86.4%), and were English proficient (76.3%). Approximately 1 of 4 women reported that they were US born (22.1%). Beyond these broader trends, Asian American nationalities varied significantly with respect to demographic, acculturation, and health care access characteristics.

Rates of Screening by Survey Year, Age, and Asian Nationality Table 2 presents rates of Pap test and mammography receipt by survey year and age among Asian American women. Pap testing rates remained stable over time, but all rates were below the recommended level of screening, ranging from 77.3% in 2001 to 80.8% in

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American Journal of Public Health | February 2015, Vol 105, No. 2

2101 2188

2384

2532

2003 2005

2007

2009

3034

3216 1320

40–49

50–64 65–74

6360

College graduate

3549

8318

< 200% FPL

‡ 200% FPL

poverty level (FPL)

Income as a % of federal

proficiency

3425

2527

100 English proficiency

8442

3149

50–99.99

Limited or no English

3568

25–49.99

English proficient

2612

0–24.99

% of time in United States

or higher

3250

2257

Any college or technical school

3677

£ High school

Education completed

Other

as married

Married or living

8182

2829

30–39

Marital status

1468

21–29

Age, y

2662

2001

Survey year

No.

1 119 125

443 789

370 998

1 191 917

344 524

414 652

455 347

347 336

851 172

295 552

416 190

457 284

1 104 869

361 784 140 639

364 874

387 044

308 573

333 968

326 264

292 882 323 806

285 994

Pop. Est.

Asian

71.6

28.4

23.7

76.3

22.1

26.5

29.2

22.2

54.5

18.9

26.6

29.3

70.7

23.1 9.0

23.3

24.8

19.7

21.4

20.9

18.7 20.7

18.3

%

2366

942

1039

2269

697

784

1026

800

1877

585

846

1039

2267

971 336

862

745

394

547

731

661 671

698

No.

299 792

136 762

152 266

284 287

79 505

99 584

143 001

114 378

232 631

68 409

135 514

127 334

309 081

103 604 40 944

105 440

104 788

81 778

86 823

89 132

84 067 89 374

87 158

Pop. Est.

Chinese

68.7

31.3

34.9

65.1

18.2

22.8

32.8

26.2

53.3

15.7

31.0

29.2

70.8

23.7 9.4

24.2

24.0

18.7

19.9

20.4

19.3 20.5

20.0

%

1562

481

77

1966

543

636

538

324

1207

497

339

676

1366

580 225

502

476

260

274

456

394 387

532

No.

322 551

93 740

14 754

401 537

95 070

134 141

117 223

69 578

245 676

102 770

67 845

122 344

293 886

111 053 45 735

97 926

91 427

70 151

84 579

92 702

75 394 87 122

76 495

Pop. Est.

Filipino

77.5

22.5

3.5

96.5

22.9

32.2

28.2

16.7

59.0

24.7

16.3

29.4

70.6

26.7 11.0

23.5

22.0

16.9

20.3

22.3

18.1 20.9

18.4

%

1003

154

77

1080

774

208

98

77

633

334

190

445

712

343 196

319

199

100

188

279

212 218

260

No.

103 286

15 461

8713

110 033

78 063

21 896

10 842

7946

61 569

34 464

22 714

34 991

83 755

32 665 22 400

30 293

21 403

11 986

22 653

23 976

25 425 23 171

23 521

Pop. Est.

Japanese

87.0

13.0

7.3

92.7

65.7

18.4

9.1

6.7

51.8

29.0

19.1

29.5

70.5

27.5 18.9

25.5

18.0

10.1

19.1

20.2

21.4 19.5

19.8

%

1325

640

1068

897

144

556

734

528

1121

278

566

536

1427

468 305

565

435

192

551

345

286 353

430

No.

116 315

48 140

79 174

85 280

25 661

42 220

52 660

43 757

98 206

22 145

44 104

49 721

114 399

33 970 12 555

43 209

37 192

37 528

41 423

32 886

30 686 32 893

26 567

Pop. Est.

Korean

70.7

29.3

48.1

51.9

15.6

25.7

32.1

26.6

59.7

13.5

26.8

30.3

69.7

20.7 7.6

26.3

22.6

22.8

25.2

20.0

18.7 20.0

16.2

%

804

149

42

911

93

234

312

314

744

111

98

182

770

154 33

210

366

190

189

209

188 189

178

No.

126 098

22 591

5349

143 340

16 482

33 394

46 209

52 604

116 753

16 909

15 027

27 958

120 702

19 002 3568

29 820

59 747

36 553

37 023

30 182

26 123 34 983

20 378

Pop. Est.

South Asian

84.8

15.2

3.6

96.4

11.1

22.5

31.1

35.4

78.5

11.4

10.1

18.8

81.2

12.8 2.4

20.1

40.2

24.6

24.9

20.3

17.6 23.5

13.7

%

735

932

986

681

56

446

663

499

423

254

990

535

1131

527 175

401

391

173

627

216

220 238

366

No.

48.1

51.9

53.5

46.5

11.4

27.0

33.1

28.6

27.5

16.7

55.9

32.5

67.5

26.9 6.0

21.6

24.3

21.1

21.7

21.8

18.4 20.8

17.3

%

Continued

82 643

89 110

91 806

79 947

19 526

46 280

56 745

49 007

47 157

28 660

95 936

55 858

115 872

46 244 10 320

37 172

41 770

36 247

37 221

37 516

31 648 35 704

29 665

Pop. Est.

Vietnamese

TABLE 1—Sample Characteristics of Asian American Women Aged 21–74 Years, by Nationality, Sample Sizes, Weighted Population Estimates (Pop Est), and Weighted Percentages: California Health Interview Survey, 2001–2009

24.6

42.9 73 603 6.3 9337 81 24.3 39 913 591 15.8 65 922 305 20.2 Note. FPL = federal poverty level; HMO = health maintenance organization.

88 115 674 19.6 2727 Fair/poor

306 436

391 65.3

28.5 42 303

97 050 591

281 35.6

40.1 65 948

58 560 709

664

816 10.4 12 311

42 155

117

32.5 55 842

28.1 312

728 53.3

30.9 128 436

221 933 1123

615 32.0

47.8 208 745

139 482 1045

1588 49.6

30.7 480 381 3667 Good

775 700 5469 Excellent/very good

General health status

1415 85.4

14.6 21 681

127 008 826

127 26.8

73.2 120 429

44 026 419

1546

February 2015, Vol 105, No. 2 | American Journal of Public Health

458

61.6

33 326

17.0 29 151

73 110

83.0 142 602

8.9

1050

107 9.1

90.9 378 393

37 899 198

1845 87.2

12.8 55 794

380 305 2918

388 13.6

86.4 1 349 278

213 181 1580

10 285 Yes

Has a usual source of care

No or usual source is the emergency department

42.6 63 301 416 44.3 72 781 855 537 45.1 187 281 932 42.4 184 346 1391 44.1 687 266 5305 ‡3

252

91.1

10 529

48.2

108 218

33.8

81 791 823 45.1

57 315

53 472

18.0 30 480 13.4

44.1 65 522

19 866 126

411 30.6

25.1 41 293

50 272 688

420

546 39.6 46 960 461

157 10.4

44.5 184 970

43 134 226

882 39.2

18.4 80 097

170 352 1320

587 16.1

4629 1–2

250 587 1892 0

in past 12 mo

39.8

25.6 38 065 207 13.1 21 503 207 168 18.3 76 306 346 14.8 64 440 488 16.3 255 375 1701 Some private non-HMO No. of times saw a physician

619 703

153

276 15.3 18 109

10.1 17 408 13.3 15 736

5.1

45.4

8781

77 968 675 60.7

1.8 2615

90 246 605

21 3.7

42.1 69 280

6021 72

809

111 1.5

66.7

1828

79 260 747

30 5.4

59.6 247 940

22 685 117

1211 56.7

5.1 22 302

247 559 1957

120 4.4

55.4 Some private HMO

68 111 511

6423

Public only non-HMO

865 037

20.2

19.1

34 756

32 841 457

271 10.1

1.9 2799

14 964 88

32 9.0

32.1 52 853

14 798 298

5.5

12.9

6546 60 8.2

8.4 35 053

34 307 179

190 9.4

14.0 61 126

40 982 342

400 14.2

9.7 151 682

1670

1561 Public only HMO

222 562

152

15 376

579

Multivariate Results

Uninsured

Health insurance

TABLE 1—Continued

2007. In 2007, Chinese (77.5%) and Korean (78.0%) women had the lowest rates of Pap test receipt, whereas Japanese women had the highest (85.5%). A trend across Asian American nationalities was that women between ages 21 and 29 had the lowest rates of Pap testing compared with other age groups. Mammography rates for Asian American women in aggregate rose from 76.0% in 2001 to 82.6% in 2009. In disaggregated analyses, mammography rates rose over time for most Asian American ethnic groups, with the greatest increases among Vietnamese, Chinese, and Japanese women. However, rates of mammography may have declined among South Asian women between 2001 and 2009. Relative to the Healthy People 2020 recommendations, all Asian nationalities met the objectives of 81.1% except Korean (64.7%) and South Asian (69.7%) women in 2009.

Predictive margins calculated from multivariate results for Pap test and mammography receipt, respectively, are presented in Tables 3 and 4. Pap test rates remained stable over time, with no significant changes by survey year for nearly all Asian nationalities with the exception of South Asian women who increased screening rates from 72.5% in 2001 to 83.4% in 2007 (Table 3). Results among Asian women in aggregate, which are presented in the first regression column, indicated that Filipino women were more likely to receive Pap tests compared with Chinese women (83.5% vs 77.6%; P < .001). Asian American women who were aged 30 to 39 years and 40 to 49 years were significantly more likely to have Pap tests compared with those aged 21 to 29 years for all Asian American ethnic groups except Korean women. Unmarried women from all Asian American ethnic groups, except Korean women, were significantly less likely to receive Pap tests compared with their married counterparts. This difference was particularly striking for South Asian women (83.8% vs 56.2%; P < .001). Asian American women in aggregate, Filipino women, and Korean women with less than a college degree were less likely to receive Pap tests compared with college graduates. Asian American women who spent more time in the United States were more likely to report Pap test receipt. This finding was true for Asian American

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American Journal of Public Health | February 2015, Vol 105, No. 2

1818

1870

1923

1251

2331

2210

2073

7865

2003

2005

2007

Age, y 21–29

30–39

40–49

50–64

Total

1198

2007

2009

1315

4521

65–74

Total

80.1 (78.3, 81.7)

79.5 (76.4, 82.3)

80.3 (78.0, 82.4)

82.6 (77.2, 86.9)

81.2 (77.7, 84.3)

80.2 (76.4, 83.6)

76.0 (72.1, 79.4) 79.1 (75.3, 82.4)

79.0 (77.6, 80.4)

82.0 (79.8, 84.0)

85.3 (83.3, 87.1)

83.2 (81.2, 85.1)

63.6 (59.3, 67.6)

80.8 (77.6, 83.6)

78.3 (75.0, 81.2)

79.6 (76.8, 82.1)

77.3 (74.9, 79.6)

% (95% CI)

Asian

1306

335

971

251

340

253

206 256

2344

692

659

634

359

594

586

560

604

No.

78.4 (75.2, 81.3)

79.2 (72.7, 84.4)

78.1 (74.2, 81.5)

81.2 (71.4, 88.3)

83.3 (79.1, 86.8)

82.4 (76.3, 87.1)

71.9 (63.6, 79.0) 72.7 (63.8, 80.0)

75.1 (72.5, 77.5)

80.9 (76.8, 84.5)

84.0 (80.2, 87.1)

79.4 (75.3, 82.9)

53.8 (46.7, 60.8)

77.5 (71.4, 82.6)

76.6 (71.4, 81.1)

73.5 (68.4, 78.1)

72.5 (67.6, 76.9)

% (95% CI)

Chinese

799

224

575

157

196

152

156 138

1466

396

412

426

232

351

322

351

442

No.

No.

737

222

249

176

82.6 (78.3, 86.2)

79.1 (72.0, 84.7)

84.1 (78.6, 88.4)

82.6 (70.6, 90.4)

83.4 (74.9, 89.4)

79.9 (70.3, 87.0)

81.1 (71.8, 87.9) 86.6 (79.3, 91.6)

90

205

168

162

202

539

196

343

106

144

100

88 101

Mammography

86.6 (83.8, 89.0)

90.0 (86.2, 92.8)

91.7 (87.9, 94.4)

88.7 (83.8, 92.3)

73.5 (63.8, 81.4)

82.2 (75.9, 87.1)

85.6 (78.6, 90.5)

91.8 (86.3, 95.2)

87.4 (82.6, 91.0)

Papanicolaou Test

% (95% CI)

Filipino

86.1 (81.9, 89.5)

90.1 (83.0, 94.4)

83.4 (77.6, 88.0)

93.3 (83.3, 97.5)

86.4 (77.4, 92.2)

80.0 (68.4, 88.1)

82.0 (69.4, 90.2) 88.8 (78.0, 94.7)

82.7 (78.4, 86.4)

81.6 (73.6, 87.6)

91.0 (86.0, 94.3)

85.4 (76.4, 91.4)

63.9 (48.4, 77.0)

85.5 (76.2, 91.6)

85.4 (78.3, 90.4)

78.3 (67.7, 86.2)

82.1 (72.9, 88.7)

% (95% CI)

Japanese

772

305

467

274

147

125

134 92

1166

275

391

347

153

266

294

249

357

No.

65.2 (59.3, 70.7)

63.8 (53.8, 72.8)

65.7 (58.3, 72.4)

64.7 (52.6, 75.1)

64.4 (51.1, 75.7)

69.1 (53.3, 81.4)

57.6 (46.1, 68.3) 68.7 (54.2, 80.4)

73.0 (69.0, 76.7)

69.0 (61.0, 75.9)

77.7 (72.4, 82.3)

76.9 (71.1, 81.9)

64.4 (50.1, 76.5)

78.0 (69.3, 84.8)

70.0 (62.0, 76.9)

70.9 (61.4, 78.9)

72.9 (67.7, 77.6)

% (95% CI)

Korean

186

33

153

47

44

36

30 29

711

99

151

296

165

192

176

180

163

No.

79.5 (71.3, 85.8)

81.9 (50.3, 95.3)

79.0 (70.4, 85.7)

69.7 (54.3, 81.6)

82.8 (56.3, 94.8)

84.0 (59.3, 95.0)

91.6 (73.1, 97.7) 79.0 (59.4, 90.6)

79.4 (75.1, 83.2)

81.7 (67.7, 90.5)

85.3 (79.0, 90.0)

84.8 (78.1, 89.8)

65.5 (55.1, 74.7)

79.7 (68.9, 87.4)

80.7 (73.2, 86.5)

80.7 (71.3, 87.5)

75.2 (66.4, 82.3)

% (95% CI)

South Asian

699

173

526

302

89

99

125 84

900

279

228

277

116

190

206

190

314

No.

82.2 (77.2, 86.3)

78.8 (67.0, 87.1)

83.0 (77.2, 87.6)

93.6 (89.9, 96.0)

76.9 (63.0, 86.7)

82.4 (70.1, 90.4)

75.9 (65.2, 84.1) 80.0 (64.7, 89.7)

76.1 (72.1, 79.7)

78.1 (71.1, 83.8)

76.6 (68.2, 83.4)

81.5 (74.7, 86.8)

65.6 (53.1, 76.2)

84.6 (77.2, 90.0)

75.7 (66.8, 82.8)

72.2 (62.8, 80.0)

69.3 (62.1, 75.7)

% (95% CI)

Vietnamese

Note. CI = confidence interval. Women who reported a hysterectomy were not asked the Papanicolaou test questions in 2005, so they were excluded from all years for consistency. The Papanicolaou test questions were not asked for the CHIS 2009 survey. Percentages are percentages of the row total.

3206

50–64

Age, y

799

1010

2005

778 736

2001 2003

Survey year

2254

2001

Survey year

No.

TABLE 2—Weighted Percentages of Papanicolaou Test and Mammography Use Reported by Asian American Women, by Nationality, Age, and Survey Year: California Health Interview Survey (CHIS), 2001–2009

81.2 (78.4, 83.9)

2007

81.4*** (79.2, 83.6)

50–65 Marital status

February 2015, Vol 105, No. 2 | American Journal of Public Health

77.1 (74.0, 80.2)

78.2 (75.6, 80.7)

79.5 (77.8, 81.3)

< 200% FPL

‡ 200% FPL (Ref)

level (FPL)

Income as a % of federal poverty

proficiency

79.8 (78.1, 81.6)

87.8*** (85.6, 90.1)

100

Limited/no English

83.8*** (81.4, 86.2)

50–99.99

English proficiency English proficient (Ref)

77.5*** (74.7, 80.4)

25–49.99

0–24.99 (Ref)

% of time in United States

68.0 (64.9, 71.0)

80.7 (78.8, 82.6)

school College graduate or

higher (Ref)

77.4 (74.6, 80.3)

77.1* (74.2, 80.0)

Any college or technical

69.5*** (66.7, 72.2)

£ High school

Education completed

Other

married (Ref)

83.3 (81.9, 84.6)

84.9*** (83.1, 86.7)

40–49

Married or living as

81.2*** (79.3, 83.2)

30–39

21–29 (Ref)

68.3 (64.3, 72.2)

77.7 (74.9, 80.5)

2005

Age, y

77.9 (75.7, 80.1) 79.5 (77.0, 81.9)

76.6 (73.6, 79.6)

72.4 (67.9, 76.9)

76.2 (71.5, 80.8)

74.7 (71.4, 78.0)

84.9***(80.2, 89.6)

84.1*** (79.1, 89.0)

72.7* (68.5, 76.8)

64.7 (59.7, 69.8)

76.4 (73.0, 79.7)

73.4 (67.9, 78.9)

74.4 (69.7, 79.1)

66.0*** (61.2, 70.8)

79.7 (77.0, 82.4)

79.6*** (75.8, 83.5)

83.7*** (80.5, 87.0)

76.6*** (72.8, 80.4)

61.2 (54.6, 67.8)

78.2 (72.7, 83.7)

75.5 (71.5, 79.4)

73.8 (69.7, 77.8) 73.6 (69.3, 77.8)

PM (95% CI)

PM (95% CI)

2001 (Ref) 2003

Survey year

Chinese

Asian

86.6 (83.6, 89.6)

86.5 (81.7, 91.3)

85.2 (73.1, 97.3)

86.7 (84.0, 89.3)

92.1*** (89.1, 95.0)

90.2*** (86.5, 93.9)

85.8** (80.3, 91.2)

71.8 (63.9, 79.7)

88.7 (85.8, 91.6)

83.2* (78.4, 88.0)

83.8 (77.0, 90.6)

79.5*** (74.6, 84.4)

90.2 (87.6, 92.8)

88.9** (85.3, 92.5)

91.2*** (87.8, 94.6)

88.4** (84.3, 92.6)

76.7 (68.7, 84.8)

82.2 (77.2, 87.3)

86.6 (81.4, 91.7)

86.5 (81.9, 91.0) 91.6 (87.4, 95.8)

PM (95% CI)

Filipino

83.9 (79.7, 88.0)

77.2 (66.1, 88.4)

86.6 (77.1, 96.0)

82.3 (78.1, 86.5)

86.5*** (81.8, 91.2)

83.9** (77.0, 90.8)

82.5** (70.7, 94.3)

53.6 (33.8, 73.4)

81.8 (76.5, 87.2)

84.6 (79.0, 90.2)

82.1 (75.1, 89.2)

76.8** (70.8, 82.7)

85.9 (81.6, 90.1)

75.5 (68.6, 82.3)

88.9** (84.8, 92.9)

88.4* (82.2, 94.6)

75.8 (65.4, 86.2)

85.7 (79.5, 92.0)

81.7 (75.2, 88.2)

82.0 (74.1, 89.9) 81.4 (74.3, 88.5)

PM (95% CI)

Japanese

72.9 (68.1, 77.7)

73.3 (65.4, 81.2)

72.9 (68.0, 77.8)

73.3 (67.5, 79.0)

89.3** (81.2, 97.5)

82.7*** (76.9, 88.6)

68.4 (57.9, 78.9)

64.4 (57.4, 71.4)

79.5 (74.0, 85.1)

56.3*** (44.4, 68.2)

69.2* (61.5, 76.9)

70.5 (62.8, 78.2)

73.9 (69.8, 78.0)

69.6 (62.6, 76.7)

80.3 (75.8, 84.8)

72.7 (66.6, 78.9)

64.6 (49.0, 80.1)

76.4 (66.7, 86.1)

68.3 (61.6, 75.1)

75.7 (70.5, 81.0) 72.2 (64.8, 79.6)

PM (95% CI)

Korean

78.6 (74.2, 83.1)

82.8 (74.4, 91.1)

65.4 (44.8, 85.9)

79.9 (75.8, 84.0)

93.1*** (88.7, 97.5)

82.3* (74.4, 90.1)

84.7** (78.3, 91.1)

69.8 (62.9, 76.8)

79.0 (74.5, 83.5)

81.1 (71.3, 90.9)

80.5 (69.1, 92.0)

56.2*** (44.2, 68.3)

83.8 (80.2, 87.3)

79.0 (65.6, 92.4)

84.4* (78.7, 90.1)

82.4* (76.8, 88.0)

73.1 (65.4, 80.9)

83.4* (76.8, 90.0)

79.3 (72.3, 86.3)

72.5 (65.0, 80.1) 79.8 (72.7, 87.0)

PM (95% CI)

South Asian

Continued

76.4 (69.7, 83.2)

75.5 (69.6, 81.4)

71.6 (65.3, 77.9)

81.6 (75.5, 87.8)

94.6** (88.2, 100.0)

78.8* (71.0, 86.6)

74.6* (67.1, 82.0)

65.3 (58.3, 72.3)

74.9 (66.2, 83.6)

73.3 (62.8, 83.9)

76.8 (72.0, 81.7)

63.0*** (54.5, 71.5)

81.4 (77.2, 85.5)

82.9*** (77.7, 88.1)

77.5** (70.5, 84.4)

76.6* (70.1, 83.2)

58.6 (46.5, 70.7)

81.5 (74.4, 88.6)

75.3 (67.7, 83.0)

72.7 (66.5, 78.8) 74.0 (66.6, 81.4)

PM (95% CI)

Vietnamese

TABLE 3—Predictive Margins (PMs) From Multivariate Analyses for Asian American Women Aged 21–65 Years, by Nationality Reporting a Papanicolaou Test in the Past 3 Years: California Health Interview Survey, 2001–2009

RESEARCH AND PRACTICE

Chawla et al. | Peer Reviewed | Research and Practice | e103

78.3 (71.8, 84.7)

74.8 (68.0, 81.7)

Southeast Asian

Other/multiple

Asian types

78.6 (74.8, 82.4) 80.0 (76.5, 83.5) South Asian Vietnamese

75.0 (70.3, 79.6)

76.8 (72.8, 80.7) Korean

Japanese

77.6 (75.4, 79.8)

83.5** (80.6, 86.3) Filipino

Chinese (Ref)

emergency department

Asian nationality

e104 | Research and Practice | Peer Reviewed | Chawla et al.

Note. CI = confidence interval; HMO = health maintenance organization. The weighting factor used for each CHIS cycle was 0.2. Women who reported a hysterectomy were not asked the Papanicolaou test questions in 2005, so they were excluded from all years for consistency. The Papanicolaou test questions were not asked for the CHIS 2009 survey. *P < .05; **P < .01; ***P < .001.

76.0 (71.8, 80.2) 75.1 (65.7, 84.5) 81.6 (77.2, 86.1) 71.0 (59.1, 83.0) 72.8 (67.9, 77.7) 73.6 (64.4, 82.8) 83.4 (79.0, 87.8) 79.2 (68.3, 90.1) 87.5 (84.8, 90.2) 82.0 (73.5, 90.5) 76.0 (73.3, 78.7) 72.0 (64.9, 79.1) 79.9 (78.5, 81.3) 75.7* (71.7, 79.7) Yes (Ref) No or usual source is

Has a usual source of care

78.2 (71.9, 84.4)

80.3 (75.3, 85.3) 87.0 (81.7, 92.3) 81.9 (76.3, 87.4) 88.0 (83.0, 93.0) 82.8 (79.4, 86.3) ‡ 3 (Ref)

84.8 (83.0, 86.6)

89.9 (86.4, 93.5)

60.4*** (49.9, 70.9) 71.9** (62.2, 81.7)

75.6** (69.7, 81.6) 74.6* (68.8, 80.4)

58.8** (49.8, 67.8) 57.7*** (45.9, 69.5)

88.7 (84.1, 93.3) 86.4 (83.1, 89.7) 76.0** (72.1, 79.8) 80.1*** (78.0, 82.1)

76.6** (67.7, 85.4) 60.8*** (54.9, 66.7) 65.1*** (61.3, 68.9) 0

in past 12 mo

No. of times saw a physician

77.2 (73.7, 80.7) 76.0 (70.7, 81.4) 80.7 (78.6, 82.8) 78.7 (75.8, 81.7)

1–2

77.6 (70.7, 84.5) 83.3 (71.8, 94.8) 82.8 (77.4, 88.1) 80.0 (72.6, 87.3) 76.6 (69.7, 83.5) 69.4 (59.1, 79.8) 83.3 (77.8, 88.7) 86.9 (79.5, 94.4)

72.8 (63.9, 81.7)

Some private HMO (Ref) Some private non-HMO

85.9 (81.9, 89.9) 84.5 (79.6, 89.3)

72.7 (37.5, 100.0)

63.2** (48.3, 78.2) 69.5 (62.8, 76.2)

79.9 (70.2, 89.6) 66.4 (46.9, 85.9)

78.0 (64.8, 91.1) 88.7 (83.4, 94.1)

74.6 (65.4, 83.8) 79.2 (75.1, 83.3)

92.2 (85.2, 99.1)

69.2* (63.5, 75.0) 75.2** (72.2, 78.3)

Public only

Uninsured

Health insurance

TABLE 3—Continued

73.8 (66.8, 80.7)

RESEARCH AND PRACTICE

women aggregated and all Asian American ethnic groups, with US-born Asian women reporting the highest screening rates. Women from all Asian American ethnic groups with fewer physician visits in the past 12 months also had lower Pap test rates compared with those with 3 or more visits. Uninsured Asian women in aggregate and uninsured South Asian and Chinese women were less likely to report receiving a Pap test compared with their insured counterparts, but this finding was not consistent for the other Asian nationalities. Table 4 presents the multivariate results for mammography receipt, which indicate an upward trend over time, with increasing rates of mammography for Asian American women overall and Chinese, Japanese, and Vietnamese women between 2001 and 2009. In 2009, Japanese (93.8%) and Vietnamese (92.9%) women had the highest rates of mammography receipt (83.9%), whereas Korean (63.3%) and South Asian (73.0%) women had the lowest after controlling for other factors. Among Asian American women in aggregate, Korean women were less likely than Chinese women to receive mammograms (72.1% vs 80.3%; P < .01), whereas Vietnamese women were more likely (86.3% vs 80.3%; P < .05). Unmarried Asian women in aggregate, Filipino women, and South Asian women were less likely to receive mammograms compared with married women. Neither education nor income level was a significant predictor of mammography receipt. Women who reported being in the United States for longer reported higher mammography rates, except Korean, South Asian, and Vietnamese women. Compared with women with 3 or more physician visits in the past year, Asian women with fewer visits had significantly lower rates of mammography. Notably, uninsured Asian women overall, Filipino women, and Japanese women were less likely to report receiving a mammogram; additionally, Asian women overall, Chinese women, and Vietnamese women without a usual source of care were also less likely to receive mammograms in the past 2 years.

DISCUSSION The purpose of our study was to examine patterns of cervical and breast cancer screening among Asian American women in California

American Journal of Public Health | February 2015, Vol 105, No. 2

80.6 (77.1, 84.0) 81.8* (78.5, 85.1) 81.8* (77.5, 86.0)

2005

2007

2009

February 2015, Vol 105, No. 2 | American Journal of Public Health

82.0 (80.2, 83.8)

79.6 (75.2, 83.9) 84.5 (82.1, 86.9) 75.6** (68.6, 82.7)

Public only Some private HMO (Ref)

Some private non-HMO

Uninsured

69.6*** (63.7, 75.6)

‡ 200 FPL (Ref)

Health insurance

79.6 (76.8, 82.5) 80.2 (77.7, 82.7)

< 200 FPL

level (FPL)

Income as a % of federal poverty

English proficient (Ref) Limited/no English proficiency

81.0 (78.4, 83.6) 78.4 (75.0, 81.7)

86.2*** (81.9, 90.4)

English proficiency

82.6*** (79.7, 85.5)

100

80.6*** (77.5, 83.7)

50–99.99

25–49.99

0–24.99 (Ref)

70.9 (65.7, 76.1)

80.6 (77.9, 83.2)

College graduate or higher (Ref) % of time in the United States

0–49.99 (Ref)

80.2 (76.6, 83.9) 78.0 (73.7, 82.3)

Any college or technical school

74.7*** (70.9, 78.5)

£ High school

Education completed

Other

Married or living as married (Ref)

Marital status

50–64 (Ref) 65–74

80.7 (78.3, 83.0) 78.2 (74.3, 82.1)

78.8 (75.1, 82.4)

Age, y

75.6 (72.0, 79.3)

2003

75.5 (65.5, 85.5)

77.0 (67.7, 86.3) 81.7 (76.5, 86.8)

71.3 (60.6, 81.9)

80.3 (76.4, 84.1)

75.7 (70.0, 81.5)

79.7 (74.7, 84.7) 77.1 (72.3, 82.0)

86.1** (79.7, 92.5)

76.0 (69.1, 82.9)

81.5* (76.8, 86.3)

72.3 (65.8, 78.9)

78.3 (73.4, 83.1)

71.5 (62.9, 80.1)

80.6 (76.4, 84.8)

76.5 (70.0, 83.0)

78.8 (75.4, 82.3)

77.8 (73.1, 82.5) 79.3 (71.1, 87.5)

81.4* (75.0, 87.7)

83.8** (79.9, 87.6)

81.7* (75.6, 87.9)

73.0 (65.2, 80.8)

70.2 (61.9, 78.6)

PM (95% CI)

PM (95% CI)

2001 (Ref)

Survey year

Chinese

Asian

73.8** (61.9, 85.7)

81.1* (74.2, 88.1) 89.3 (85.4, 93.3)

63.5** (43.5, 83.6)

82.4 (77.7, 87.1)

82.7 (76.6, 88.8)

82.7 (78.5, 87.0) 80.1 (67.3, 92.9)

83.5* (73.9, 93.0)

87.4*** (82.7, 92.1)

84.5** (79.0, 90.0)

65.9 (55.3, 76.6)

82.7 (78.6, 86.8)

84.7 (78.0, 91.4)

80.1 (71.1, 89.2)

75.5** (68.4, 82.6)

86.2 (82.4, 90.0)

84.1 (79.7, 88.5) 79.1 (72.1, 86.0)

84.2 (77.8, 90.6)

83.1 (76.2, 90.1)

81.6 (73.8, 89.3)

83.8 (77.1, 90.5)

78.8 (69.8, 87.8)

PM (95% CI)

Filipino

75.2* (59.2, 91.3)

90.6 (84.6, 96.6) 89.2 (84.9, 93.5)

36.6*** (6.9, 66.2)

86.0 (82.1, 89.9)

86.7 (79.7, 93.7)

85.2 (81.0, 89.4) 91.9 (84.9, 98.8)

89.7*** (86.0, 93.4)

83.0* (75.5, 90.4)





65.0 (45.9, 84.2)

85.4 (79.8, 91.0)

86.0 (80.8, 91.3)

87.2 (81.6, 92.8)

86.1 (81.7, 90.6)

86.1 (81.6, 90.5)

86.8 (82.6, 91.0) 84.7 (78.4, 91.0)

93.8** (89.6, 97.9)

86.5 (80.5, 92.5)

83.1 (74.7, 91.5)

86.3 (79.2, 93.5)

80.8 (72.4, 89.2)

PM (95% CI)

Japanese

71.5 (54.5, 88.5)

68.1 (56.4, 79.8) 68.7 (57.6, 79.7)

58.9 (48.1, 69.7)

68.9 (61.1, 76.7)

60.9 (52.5, 69.2)

69.4 (59.8, 79.0) 64.1 (57.3, 70.8)

79.6 (55.2, 100.0)

69.7 (59.6, 79.9)

63.0 (55.6, 70.5)

63.7 (53.6, 73.9)

70.0 (62.7, 77.3)

65.3 (54.7, 76.0)

62.5 (54.8, 70.3)

60.1 (51.4, 68.8)

67.0 (60.8, 73.1)

67.1 (59.6, 74.6) 60.8 (49.8, 71.8)

63.3 (52.5, 74.1)

63.3 (53.4, 73.2)

66.5 (55.3, 77.6)

69.1 (58.4, 79.7)

63.7 (54.2, 73.1)

PM (95% CI)

Korean

80.6 (62.4, 98.8)

73.0 (39.2, 100.0) 82.9 (74.9, 90.9)

70.3 (48.9, 91.8)

78.8 (70.6, 86.9)

81.6 (62.9, 100.0)

79.9 (72.7, 87.1) 74.4 (31.5, 100.0)

86.5 (60.3, 100.0)

83.8 (74.2, 93.4)

95.6*** (89.3, 100.0)

58.9 (34.4, 83.5)

76.5 (65.9, 87.1)

82.1 (63.8, 100.0)

85.7 (71.3, 100.0)

56.1* (31.8, 80.4)

87.1 (77.2, 97.0)

76.5 (67.2, 85.8) 90.4 (70.9, 100.0)

73.0 (64.7, 81.2)

76.0 (58.8, 93.2)

90.4 (81.8, 98.9)

74.4 (53.4, 95.4)

86.9 (64.9, 100.0)

PM (95% CI)

South Asian

Continued

90.8 (79.6, 100.0)

79.9 (71.7, 88.2) 86.0 (76.4, 95.7)

77.3 (68.4, 86.3)

75.8 (62.9, 88.7)

83.8 (79.2, 88.4)

85.5 (75.0, 96.1) 81.2 (75.9, 86.6)



83.9 (73.7, 94.1)

83.3 (76.3, 90.4)

80.1 (72.4, 87.7)

83.4 (72.4, 94.4)

74.5 (58.5, 90.4)

82.4 (77.4, 87.4)

85.6 (78.8, 92.4)

80.1 (74.0, 86.2)

83.2 (77.9, 88.4) 76.3 (65.7, 86.9)

92.9*** (89.2, 96.7)

82.7 (73.0, 92.4)

80.7 (69.4, 92.0)

78.1 (64.7, 91.5)

72.9 (62.3, 83.4)

PM (95% CI)

Vietnamese

TABLE 4—Predictive Margins (PMs) From Multivariate Analyses for Asian American Women Aged 50–74 Years, by Nationality Reporting a Mammogram in the Past 2 Years: California Health Interview Survey (CHIS), 2001–2009

RESEARCH AND PRACTICE

Chawla et al. | Peer Reviewed | Research and Practice | e105

78.6 (71.6, 85.6) 86.3* (82.7, 90.0)

78.2 (65.1, 91.3)

83.3 (73.7, 92.9)

South Asian Vietnamese

Southeast Asian

Other/multiple Asian types

e106 | Research and Practice | Peer Reviewed | Chawla et al.

Note. CI = confidence interval; HMO = health maintenance organization. Sample for Japanese living in United States for 0%–24.99% and 25%–49.99% had to be combined because of small cell sizes. The weighting factor used for each CHIS cycle was 0.2. *P < .05; **P < .01; ***P < .001.

79.2 (73.7, 84.6)

72.1** (67.2, 77.0) Korean

79.5 (75.7, 83.4) Filipino

Japanese

80.3 (77.3, 83.3) Chinese (Ref)

Asian nationality

83.6 (78.9, 88.3)

86.5 (82.1, 91.0)

82.9 (74.4, 91.4)

68.9* (53.8, 84.1) 85.6 (70.5, 100.0)

78.4 (70.8, 86.0) 65.5 (59.0, 72.0)

64.1 (52.6, 75.7) 91.7 (85.1, 98.2)

85.5 (81.5, 89.4) 82.9 (78.7, 87.1)

78.5 (67.2, 89.8) 60.9** (45.2, 76.6)

80.6 (77.4, 83.8) 80.8 (78.9, 82.8)

73.2* (66.8, 79.5) No or usual source is emergency department

Has a usual source of care Yes (Ref)

93.6 (84.7, 100.0) 78.1 (72.2, 83.9) 92.7 (89.0, 96.5) 88.9 (84.9, 92.8) 83.4 (79.0, 87.7) 86.5 (84.5, 88.5) ‡ 3 (Ref)

73.1* (60.3, 85.8)

66.6* (45.6, 87.6) 32.2*** (17.9, 46.6)

62.9** (53.0, 72.7) 89.7 (85.3, 94.1)

44.6*** (26.3, 62.8) 74.4** (63.3, 85.4)

76.9*** (70.6, 83.3) 77.9*** (74.6, 81.3) 1–2

64.0*** (54.8, 73.2) 60.8*** (54.4, 67.2) 0

No. of physician visits in past 12 mo

TABLE 4—Continued

79.1 (74.1, 84.2)

60.6*** (42.6, 78.5)

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and to assess their screening trends over time. Our findings indicate that rates of Pap test receipt were consistently below Healthy People 2020 objectives for all Asian nationalities and that mammography receipt was below these objectives for certain groups. In examining trends over time, we found no significant changes in Pap test rates, but mammography use increased among Asian American women overall, especially among Chinese and Vietnamese women. Our study confirmed striking variation among Asian American groups, with screening rates varying from 64.7% to 93.6% for mammography receipt in 2009 and from 77.5% to 85.5% for Pap test use in 2007. Notably, Chinese and Korean women had the lowest Pap test rates in 2007, and Korean and South Asian women had the lowest mammography rates in 2009. Therefore, these groups should be the focus of culturally based targeted interventions or programs to promote breast and cervical cancer screening among Asian American women. Several potential factors could help explain the variation among Asian women that we observed. One of the most consistent findings among all Asian American nationalities was that longer time in the United States was associated with increased use of cancer screening for both Pap test and mammography receipt. Surprisingly, English language proficiency was not associated with screening use. This finding could be associated with California’s relatively high proportion of in-language services offered in Asian languages, particularly in areas with a high population density of Asian Americans. Within Asian ethnic enclaves, such as Koreatown or Chinatown, for example, services are offered by health care providers of the same cultural and linguistic background.54,55 Longer time in the United States may result in changing knowledge and attitudes about the use of preventive health care services. This could help explain why increased length of time in the United States was significantly associated with higher screening rates among nearly all Asian American groups, despite lower English proficiency. More time in the United States may also enable women to have better access to and navigation of the US health care system.

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Sociodemographic and health care access factors had varied effects, with education and insurance coverage being significant predictors of screening for certain groups but not all. Contrary to expectations, income level and usual source of care did not appear to play a significant role for most women. For most groups, neither income nor insurance was a significant predictor of mammography or Pap test receipt in multivariate results. This finding is likely a result of a combination of factors. First, California State policies and programs may increase access to screening among Asian women independent of health insurance coverage. The Every Woman Counts program, cofunded by the Centers for Disease Control and Prevention and the state of California, provides in-language services to uninsured and lower-income Asian women and has more generous eligibility criteria in California than in other states.56 The Every Woman Counts program is supplemented by funding for emergency treatment from the federal government and the California tobacco tax, sometimes in collaboration with ethnic community groups. Second, a long-standing network of community-based organizations in California provide primary care services and focus outreach and education efforts on Asian Americans.41,42,57---59 Community-based organizations also work closely with California’s state-based and federal programs as well as ethnic-specific clinics to improve preventive care among Asian individuals in California. Third, several community-based organizations and clinics provide in-language navigation services, which have also been shown to improve preventive care use. Finally, California has a large HMO penetration rate, and HMOs promote the use of preventive care services.60---62 Given this context, California’s state policies and organizations targeting screening in Asians may help explain relative improvements in screening for particular Asian groups (e.g., mammography among Vietnamese women) that we found in our study. Therefore, California may provide a model of health care delivery for increasing cancer screening use among underserved ethnic populations locally and in other states. However, it is important to note that despite the availability of a variety of screening and education programs in California, we still found low and variable rates of cancer screening for breast and

cervical cancers, suggesting that underlying cultural attitudes and beliefs may play a stronger role than has been shown to date. Our study had some limitations that should be noted. First, response rates ranged from 37.7% to 17.7% during the cycles of CHIS included in our analyses and may affect generalizability of findings.49,50 However, these rates are comparable to other random-digitdial samples during the same period, such as the Behavioral Risk Factor Surveillance System.63,64 Second, the CHIS did not include measures of culturally framed health beliefs and attitudes, which may play an important role in screening behaviors and could explain some of the variation observed between groups. Thus, we were limited in our ability to explain how cultural views may affect screening for breast and cervical cancer among Asian American women. Third, for Asian women who were not offered the survey in their native language, the sample captured was more likely to include English-speaking, acculturated women who also may be more likely to be screened. Fourth, data were self-reported. Last, data were cross-sectional, prohibiting us from making causal inferences. Despite these limitations, our study had several strengths. Importantly, these findings were based on several years of pooled data that provided larger sample sizes than in other data on Asian Americans. Unlike other populationbased surveys, the CHIS was conducted in several Asian languages, which helped capture a larger, more representative sample of Asian Americans in California. CHIS data also included several important measures of sociodemographic, acculturation, and health care access factors, enabling us to examine the role of these factors in screening use among Asian American women. Finally, by measuring differences in survey year with the pooled data, we were able to detect an increase in mammography use among Asian women between 2001 and 2009. In conclusion, our findings have several implications and directions for future research. Population-based surveys should incorporate measures of health beliefs and attitudes toward health, prevention of disease, health care use, and the capacity to navigate the complex health care system to better address barriers to screening among Asian Americans. Additional

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research that uses diverse methodological approaches, such as qualitative studies, is needed to tease out the specific barriers to screening for Asian women, including structural barriers such as transportation and out-of-pocket costs, cultural and health beliefs, attitudes toward cancer, and understanding of the basic message that screening use may help prevent the onset of disease. Studies are also needed to assess the cultural sensitivity of health care practitioners and to better understand the role of patient--provider interaction and trust in providers among Asian American women. Perhaps most important, our results underscore the need for targeted interventions to increase rates of mammography and Pap test use among specific Asian nationalities. j

About the Authors Neetu Chawla is with Outcomes Research Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD. Nancy Breen is with Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute. Benmei Liu is with Statistical Methodology and Applications Branch, Surveillance Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute. Richard Lee is with Information Management Services, Inc, Calverton, MD. Marjorie Kagawa-Singer is with UCLA School of Public Health and Asian American Studies Department, Los Angeles, CA. Correspondence should be sent to Neetu Chawla, PhD, MPH, Outcomes Research Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Dr, Rockville, MD 20850 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted August 8, 2014.

Contributors N. Chawla, N. Breen, and M. Kagawa-Singer contributed to the conceptualization and design of the study, data analysis and interpretation, and writing of the article. B. Liu contributed to data analysis, interpretation of results, and writing of the article. R. Lee contributed to data analysis and interpretation.

Acknowledgments The authors would like to acknowledge the support of the Cancer Prevention Fellowship Program for this research. Findings from this study have been presented at the American Public Health Association Research Meeting, October 27---31, 2012, San Francisco, CA.

Human Participant Protection Human subjects’ approval for recruitment and data collection for the California Health Interview Survey was obtained from UCLA and the state of California. Therefore, the survey was exempted from review by the National Institutes of Health, Office of Human Subjects Research Protection.

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Asian American women in California: a pooled analysis of predictors for breast and cervical cancer screening.

We examined patterns of cervical and breast cancer screening among Asian American women in California and assessed their screening trends over time...
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